Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for instructions and the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
|
Total |
||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | 393,209 | 426,433 | 946,264 | 550,478 | 723,175 | 3,039,559 |
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | 393,209 | 426,433 | 946,264 | 550,478 | 723,175 | 3,039,559 |
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | 3,039,559 | |||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | 393,209 | 426,433 | 946,264 | 550,478 | 723,175 | 3,039,559 |
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | 381,511 | 409,601 | 386,990 | 497,277 | 535,673 | 2,211,052 |
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | 5,250,611 | |||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | ||||||
| 6 | Total. Add lines 1 through 5 | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public support. (Subtract line 7c from line 6.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2016 | (b) 2017 | (c) 2018 | (d) 2019 | (e) 2020 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 0.015 of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by 0.035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | 1 | |
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
2 | |
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | 3 | |
| 4 Amounts paid to acquire exempt-use assets | 4 | |
| 5 Qualified set-aside amounts (prior IRS approval required - provide details in Part VI) | 5 | |
| 6 Other distributions (describe in Part VI). See instructions | 6 | |
| 7Total annual distributions. Add lines 1 through 6. | 7 | |
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
8 | |
| 9 Distributable amount for 2020 from Section C, line 6 | 9 | |
| 10 Line 8 amount divided by Line 9 amount | 10 | |
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2020 |
(iii) Distributable Amount for 2020 |
|
|---|---|---|---|---|
| 1 Distributable amount for 2020 from Section C, line 6 | ||||
|
2
Underdistributions, if any, for years prior to 2019 (reasonable cause required-- explain in Part VI). See instructions. |
||||
| 3 Excess distributions carryover, if any, to 2020: | ||||
| a From 2015....... | ||||
| b From 2016....... | ||||
| c From 2017....... | ||||
| d From 2018....... | ||||
| e From 2019....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2020 distributable amount | ||||
|
i
Carryover from 2015 not applied (see instructions) |
||||
| j Remainder. Subtract lines 3g, 3h, and 3i from line 3f. | ||||
| 4Distributions for 2020 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2020 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from line 4. | ||||
|
5
Remaining underdistributions for years prior to 2020, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
6
Remaining underdistributions for 2020. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
||||
|
7 Excess distributions carryover to 2021. Add lines 3j and 4c. |
||||
| 8 Breakdown of line 7: | ||||
| a Excess from 2016..... | ||||
| b Excess from 2017..... | ||||
| c Excess from 2018..... | ||||
| d Excess from 2019..... | ||||
| e Excess from 2020..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|
| Software ID: | |
| Software Version: |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| FORM 990, PART I LINE 1 - MISSION STATEMENT | ASHLAND COMMUNITY HOSPITAL FOUNDATION GENERATES AND INVESTS RESOURCES TO IMPROVE THE HEALTH OF OUR COMMUNITY. |
| FORM 990 PART III, LINE 4a - PROGRAM SERVICE ACCOMPLISHMENTS | PROGRAM SERVICE ACCOMPLISHMENTS CHARITY CARE: $724 THROUGH THE GENEROSITY OF ASANTE ASHLAND COMMUNITY HOSPITALISTS GIFTS WERE USED TO SUPPORT INPATIENTS IN NEED. COMMUNITY HEALTH INITIATIVE: $277 OVER 1,000 MITTENS, GLOVES AND HATS WERE DONATED TO STUDENTS IMPACTED BY THE ALMEDA FIRE IN THE PHOENIX-TALENT SCHOOL DISTRICT. DONOR CONTRIBUTIONS WERE USED TO SUPPORT THE PURCHASE OF MITTENS, GLOVES AND HATS. CONFERENCE ROOM $121,059 A GENEROUS ESTATE GIFT FROM SIDNEY AND BARBARA FIELD, AND OTHER DONOR DESIGNATED CONTRIBUTIONS HELPED SUPPORT THE RENOVATION OF THE HOSPITAL CONFERENCE ROOM. COVID-19 RESPONSE: $109,317 GRANTS FROM THE OREGON HEALTH AND SCIENCE UNIVERSITY SMALL HOSPITAL IMPROVEMENT PROGRAM, AND THE WILLIAM G. AND RUTH T. EVANS FUND OF THE OREGON COMMUNITY FOUNDATION SUPPORTED THE HOSPITAL'S RESPONSE TO COVID-19. DIAGNOSTIC IMAGING: $18,538 CONTRIBUTIONS TO THE CAREGIVER FUND AND OTHER DONOR DESIGNATED GIFTS SUPPORTED THE PURCHASE OF BREAST STABILIZATION EQUIPMENT IN WOMEN'S IMAGING AND THE CERTIFICATION OF MAMMOGRAPHY EQUIPMENT THROUGH THE AMERICAN COLLEGE OF RADIOLOGY. THROUGH THE GENEROSITY OF RETIRED PHYSICIAN JOHN BARTON MD, AN EMPLOYEE WAS ABLE TO ATTEND THE 2019 RADIOLOGICAL SOCIETY OF NORTH AMERICAN (RSNA) ANNUAL MEETING. IN ADDITION, AN EMPLOYEE WAS ABLE TO RECEIVE CT TRAINING THROUGH THE AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGISTS. EMPLOYEE ASSISTANCE FUND: $10,938 DONOR DESIGNATED CONTRIBUTIONS SUPPORTED 16 ASANTE ASHLAND COMMUNITY HOSPITAL EMPLOYEES EXPERIENCING A CRISIS AND FINANCIAL HARDSHIP, INCLUDING 11 EMPLOYEES DISPLACED BY THE ALMEDA FIRE. EDUCATION & PROFESSIONAL DEVELOPMENT FUND: $660 DONATIONS TO THE EDUCATION & PROFESSIONAL DEVELOPMENT FUND ENABLED AN ASANTE ASHLAND COMMUNITY HOSPITAL FAMILY BIRTH CENTER NURSE TO RECEIVE A SPECIALIZED LACTATION CERTIFICATION. ENGINEERING: $3,389 THROUGH THE GENEROSITY OF A DONOR DESIGNATED GIFT, FUNDS WERE USED TO PURCHASE A WASHER AND DRYER FOR THE ENVIRONMENTAL SERVICES DEPARTMENT. FAMILY BIRTH CENTER: $186 DONOR DESIGNATED GIFTS SUPPORTED THE PURCHASE OF A WHEELCHAIR. HOLISTIC PATIENT CARE: $3,319 DONOR DESIGNATED GIFTS SUPPORTED BOTH THE MASSAGE THERAPY PROGRAM AND THE HARPIST PROGRAM, WHICH ENHANCE PATIENT EXPERIENCE. INNOVATION: $10,000 DONOR DESIGNATED CONTRIBUTIONS SUPPORTED EDUCATION FOR HOSPITAL LEADERSHIP ON HEALTHCARE INNOVATION. MEDICAL SURGICAL UNIT: $4,022 CONTRIBUTIONS TO THE CAREGIVER FUND HELPED PURCHASE TWO SPECIALIZED PATIENT RECLINERS FOR HIGH FALL RISK PATIENTS. IN ADDITION, DONOR DESIGNATED GIFTS ALSO SUPPORTED THE PURCHASE OF MINOR EQUIPMENT FOR THE UNIT. NURSING SCHOLARSHIPS: $120,944 THE WILLIAM G. & RUTH T. EVANS ENDOWED NURSING SCHOLARSHIP SUPPORTED SCHOLARSHIPS FOR 29 STUDENTS ENROLLED IN NURSING PROGRAMS AT ROGUE COMMUNITY COLLEGE AND OREGON HEALTH & SCIENCE UNIVERSITY - ASHLAND CAMPUS. NUTRITIONAL SERVICES: $980 DONOR DESIGNATED GIFTS WERE USED TO SUPPORT THE PURCHASE OF A NEW PRINTER. PARKING LOT: $49,000 A PARCEL OF LAND IN TALENT, OREGON ADJACENT TO 209 N. PACIFIC HWY AND 49 TALENT AVENUE WAS DONATED TO ASANTE ASHLAND COMMUNITY HOSPITAL TO SUPPORT STAFF PARKING. RESPIRATORY THERAPY: $7,630 CONTRIBUTIONS TO THE CAREGIVER FUND PURCHASED TWO V30 AUTO MOBILITY UNITS. THE UNITS PROVIDE RESPIRATORY SUPPORT TO PATIENTS AND HELP EASE THEIR TRANSITION TO A HOME UNIT BEFORE DISCHARGE. SCHOOL NURSE PROGRAM: $82,977 DONOR DESIGNATED GIFTS AND GRANTS FROM THE COW CREEK UMPQUA INDIAN FOUNDATION, THE REED AND CAROLEE WALKER FUND OF THE OREGON COMMUNITY FOUNDATION, THE SHARKEY FOUNDATION, ASHLAND FOOD CO-OP AND SHOP'N KART SUPPORTED NURSING SERVICES FOR CHILDREN IN K-12 SCHOOLS IN ASHLAND, PHOENIX, AND TALENT. SMALL HOSPITAL IMPROVEMENT PROGRAM: $10,308 A GRANT FROM THE OREGON HEALTH AND SCIENCE UNIVERSITY SMALL HOSPITAL IMPROVEMENT PROGRAM (SHIP) SUPPORTED THE MEASUREMENT AND REPORTING OF PATIENT EXPERIENCE. ULTRAVIOLET TECHNOLOGY: $96,900 DONATIONS FROM THE PATRONS CAMPAIGN SUPPORTED THE PURCHASE OF TWO OPTIMUM ENLIGHT SYSTEM DEVICES, THE LATEST IN ULTRAVIOLET TECHNOLOGY, FOR THE STERILIZATION OF OPERATING ROOMS AND PATIENT CARE AREAS AT ASANTE ASHLAND COMMUNITY HOSPITAL. |
| Form 990, Part VI, Section A, line 6 | FOUNDATION BOARD MEMBERS SERVE AS VOTING MEMBERS WITH AUTHORITY AND RESPONSIBILITY TO DEVELOP POLICIES, PROCEDURES, AND REGULATIONS NECESSARY TO OPERATE THE FOUNDATION, PARTICIPATE IN FUNDRAISING THROUGH PERSONAL CONTRIBUTIONS, AND PARTICPATE IN THE VARIOUS CAMPAIGNS NECESSARY TO FINANCE THE ONGOING OPERATION OF THE FOUNDATION AND ITS WORK WITH THE HOSPITAL. BOARD MEMBERS SERVE A THREE YEAR TERM (UNLESS ELECTED TO FILL AN UNEXPIRED TERM). |
| Form 990, Part VI, Section A, line 7a | THE OFFICERS SHALL BE ELECTED BY, AND SHALL SERVE AT THE PLEASURE OF, THE BOARD, AND SHALL HOLD THEIR RESPECTIVE OFFICES UNTIL THEIR RESIGNATION, REMOVAL, OR OTHER DISQUALIFICATION FROM SERVICE, OR UNTIL THEIR RESPECTIVE SUCCESSORS SHALL BE ELECTED. THE PRESIDENT SHALL BE ELECTED FOR A TWO-YEAR TERM OF OFFICE. VICE-PRESIDENT, SECRETARY AND TREASURER SHALL BE ELECTED ANNUALLY. |
| Form 990, Part VI, Section A, line 7b | FOUNDATION BOARD MEMBERS ARE EXPECTED TO ATTEND MONTHLY BOARD MEETINGS, STANDING COMMITTEES (AS ASSIGNED), AD HOC COMMITTEE MEETINGS (AS APPOINTED) AND SPECIAL EVENTS (AS ANNOUNCED). CONTINUITY OF ATTENDANCE AND PARTICIPATION AS A POLICY MAKER AND PLANNER IS IMPERATIVE FOR SERVING AS A VOTING MEMBER. |
| Form 990, Part VI, Section B, line 11b | THE ACH FOUNDATION HAS A STANDING ASSET MANAGEMENT COMMITTEE THAT MEETS QUARTERLY TO REVIEW FINANCIAL STATEMENTS, INCLUDING EXPENSES, INCOME, GRANTS, CASH DISBURSEMENTS, BALANCE SHEET, PROFIT AND LOSS, AND ANY AUDIT LETTERS. IN ADDITION, TIME IS ALLOCATED AT EACH QUARTERLY BOARD MEETING TO REVIEW FINANCIAL STATEMENTS AND THE ANNUAL AUDIT IS PRESENTED TO THE FULL FOUNDATION BOARD UPON ITS COMPLETION. BOTH THE ASSET MANAGEMENT COMMITTEE AND THE BOARD MONITOR THE FINANCIAL RESOURCES TO ENSURE THAT FUNDS ARE APPROPRIATELY ACCOUNTED FOR. THE FOUNDATION BOARD TREASURER REVIEWS THE FINANCIAL STATEMENTS ON A MONTHLY BASIS. FINANCIAL STATEMENTS: 1. THE ACH FOUNDATION IS NOT REQUIRED BY LAW TO UNDERGO AN AUDIT BY AN INDEPENDENT AUDITOR. 2. THE ACH FOUNDATION HAS NOT RECEIVED FEDERAL FUNDS THAT REQUIRES ONE OR MORE AUDITS. 3. THE ACH FOUNDATION BOARD HAS AN ESTABLISHED ASSET MANAGEMENT COMMITTEE WHICH MAKES RECOMMENDATIONS ON THE SELECTION OF THE INDEPENDENT AUDITOR TO THE FOUNDATION BOARD. IN ADDITION, THEY OVERSEE THE INDEPENDENT AUDITOR. 4. THE ACH FOUNDATION CURRENTLY HAS FINANCIAL STATEMENTS COMPILED BY AN INDEPENDENT ACCOUNTANT AND AUDITED ANNUALLY BY A QUALIFIED THIRD-PARTY. |
| Form 990, Part VI, Section B, line 12c | ALL BOARD MEMBERS ARE EXPECTED TO ACCEPT AND ADHERE TO POLICIES AND HOLD FELLOW BOARD MEMBERS AND STAFF TO THE SAME STANDARDS. MONITORING OF SUCH IS ONGOING. |
| Form 990, Part VI, Section C, line 18 | THE FOUNDATION'S DOCUMENTS AVAILABLE FOR PUBLIC INSPECTION MAY BE REQUESTED FOR VIEWING BY CONTACTING THE FOUNDATION'S OFFICE. |
| Form 990, Part VI, Section C, line 19 | THE FOUNDATION'S FINANCIAL STATEMENTS AND GOVERNING DOCUMENTS ARE AVAILABLE UPON REQUEST AND BY VISITING THE WEBSITE WWW.ACHFOUNDATION.ORG |
| Form 990, Part XI, line 9: | CHANGE IN MARKET VALUE OF TRUST ASSETS 8,878. IN-KIND EXPENSES -225,900. GAIN ON DONATION OF REAL ESTATE 49,000. |
| FINANCIAL STATEMENT AND AUDIT OVERSIGHT | THE OVERSIGHT OR SELECTION PROCESS HAS NOT CHANGED DURING THE YEAR. |
| Software ID: | |
| Software Version: |